Arthroscopic of the knee: History and state of the art

CONRAD T. FRAIDER, DD. Philadelphia, Pennsylvania

Consequently, the arthroscope followed. Even In the orthopedic management of knee today, developments in arthroscopes always have disorders, arthroscopy not only has followed developments in cystoscopes. become useful in diagnosis but also in Modern had its start in 1805 when surgery due to technologic Bozzini devised the Lichtleiter, or light conductor, refinements in the arthroscope and for examination of the bladder. This was a crude accessory instruments combined with instrument by current standards, using a candle the expanding expertise of the for the light source. The Lichtleiter was a arthroscopist. The endoscopic origin speculum-type instrument, with a split tube, one and evolution of arthroscopy are half for viewing and one half for reflected light. 2 reviewed, as well as specific There were other investigators over the next 70 applications of arthroscopic surgical years who devised variations of the Lichtleiter and procedures and equipment for loose showed the usefulness of endoscopes in medicine. bodies, bands and adhesions, All of these scopes used reflected light. In 1876, osteochondritis dessicans, Nitze devised an instrument that had a platinum chondroplasty, lateral retinacular loop encased in a goose quill. This device also used release, meniscoresis, meniscectomy, reflected light but allowed a somewhat better than and synovectomy. The advantages previously obtained view of the bladder. Nitze was and disadvantages of arthroscopic obviously unhappy with this type of illumination, surgery are pointed out to show its because his records indicated that for optimal view- superiority over arthrotomy. ing the light source had to be at the distal tip. At this time Edison was still working on the develop- ment of the incandescent bulb. After its develop- ment, it took until 1883 to miniaturize it to fit the diameter of the endoscope. With technology finally Arthroscopy has become an integral part of the able to meet his needs, Nitze went on to develop the orthopedic management of knee disorders. It took first true endoscope,which had a prism to reflect many years from its introduction in the early 1960s light 90 degrees and a lens system that provided a to become a proven diagnostic tool. Until recently, limited amount of light transmission. diagnosis, therapeutic irrigation, occasional biop- In the next 30 years, Nitze and other investiga- sy, and removal of loose bodies have been the limits tors devised crude arthroscopes and reported on of the arthroscopist. The past 3 to 4 years have seen their findings. Takagi made the next significant the emergence of operative procedures performed contribution in 1918; he is credited with the first under arthroscopic control, due to ingenuity as true investigation into arthroscopy." He inspected well as the increasing skill and confidence of the cadaveric knees by using a 7.3 mm. cystoscope. arthroscopist. Also, the operating arthroscope with This scope was impractical for routine clinical use, an array of accessory and motorized instruments but by 1931, Takagi produced a scope with a 3.5 mm. has become available. To understand how arthro- diameter for viewing a knee distended by fluid.2 scopic surgery developed and how it is used at In 1921, Bircher published the first article on the present, this paper reviews the history of endo- arthroscopy of knees distended with carbon dioxide scopy and explains the basic arthroscope and ar- and dioxide. In 1925, Kreuscher described the use throscopic surgical procedures. of arthroscopy in the diagnosis of knee disorders, in particular, meniscal injuries.413 History of endoscopy If arthroscopic surgery is defined as any proce- The word "endoscopy" comes from the Greek word dure performed through the arthroscope, as op- "endo," meaning "within" and "skopein," meaning posed to that performed under direct arthroscopic "to examine." As mans knowledge of medicine and control, then credit for its development goes to disease increased, it seemed only natural that he Burman. In the years 1931-35, he developed his would have wanted to examine the inside of body own arthroscope as well as instruments for surgical cavities. It is from these desires that the first crude procedures. During this time he conducted exam- endoscope was developed, which was a cystoscope. inations of the hip, knee, ankle, shoulder, elbow,

Arthroecopic surgery of the knee 817/81 and wrist, and reported on his experiences.2 able. They vary in diameter from 1.7 mm. to 6.5 The "dawn of modern arthroscopy" occurred in mm. and have different angles of view. The direct- 1960 with the development of the No. 21 arthro- viewing arthroscope has a viewing range of 10 scope by Watanabe, a student of Takagi. Watanabe degrees, that is, from 170 to 180 degrees. The went on to do the first partial meniscectomy under foreoblique arthroscope, which is frequently used, arthroscopic control in 1962. From this point on has a viewing range of 30 degrees, from 135 to 165 there have been contributions by numerous other degrees. The right-angle arthroscope only has a 20 investigators: Carson, Jackson, Johnson, Joyce, degree viewing range, from 90 to 110 degrees. With McGinty, and OConnor. From their continued ef- the use of these accessory viewing angles, as well forts the arthroscope became a valid tool of the as the smaller diameters, the arthroscopist can orthopedic surgeon. visualize difficult or remote areas of a joint without making a second entry wound. The smaller diame- The arthroscope ter needle scopes allow examination of the smaller The modern arthroscope has three fundamental joints of the body. In 1976, arthroscopy was ad- parts: the mechanical system, illumination system, vanced one further step with the introduction of and optical system. Each of these systems has been the operating arthroscope. This arthroscope had an upgraded over the years, as the technology has offset eyepiece that allowed the introduction of become available, to meet the requirements of instruments under direct arthroscopic control. modern arthroscopy, that is, adequate illumina- tion, sufficient angle of view, and durability. Arthroscopic surgery The mechanical system is essentially the in- Since its introduction, arthroscopy has grown to struments rigid housing or sheath, of various become an accepted diagnostic adjunct for the or- shapes and diameters. These were originally con- thopedic surgeon. As the skill of the arthroscopist structed of brass or nickle-silver covered by nickle increased, so did his diagnostic ability. In 1971, with a smooth surface. Currently, they are stain- diagnostic arthroscopy was about 80 percent accu- less steel. The illumination system started with rate; by 1975, it was 98 percent.° Arthroscopy reflected light, advanced to the incandescent bulb, also has shown superiority over arthrography in and now is fiberoptic. Development of fiberoptics diagnosing injuries to the menisci and anterior started in 1950, but industry could not produce cruciate ligament." By combining the diagnostic fiberoptic bundles of significant quality and at a modalities of clinical examination, arthrography, reasonable cost until 1958. The development of and arthroscopy, the diagnosis of knee injuries fiberoptic bundles made the incandescent bulb ob- should be 100 percent accurate. Diagnostic ar- solete. Currently, there are three optical systems throscopy has reached the point where it can be in use: objective lens system, rod-lens system, and done on an outpatient basis, using local anes- GRIN lens system. The objective lens system thesia. 11, 12 Thus, the arthroscopist naturally would utilizes a series of lenses with large air spaces want to effect treatment through the arthroscope. which transmits the image to the eyepiece. With Prior to undertaking any arthroscopic surgery, the advent of applying computer technology to op- the orthopedic surgeon has to be an experienced tics, the rod-lens system was developed. This arthroscopist. The surgeon should have the experi- utilizes thicker lenses with smaller air spaces, re- ence of performing several hundred diagnostic sulting in a more efficient optical system. The third arthroscopies. 8, ° He must be familiar with the lens system, the GRIN system, uses a single glass many portals through which the arthroscope as well component and is found in needle scopes. 1° as accessory instruments may be introduced.0,16 The Watanabe No. 21 arthroscope was the first These portals are most commonly anterolateral, arthroscope in the United States that gained any anteromedial, posterolateral, posteromedial, lat- preference. It was a telescope that utilized an elec- eral suprapatellar, medial suprapatellar, and cen- tric light carrier sheath measuring 6.5 mm. in di- tral patellar tendon splitting. The use of a probe in ameter. The tungsten bulb provided sufficient light diagnostic arthroscopy is advocated for the palpa- for examination as well as for color photography, tion of intraarticular structures and for develop- but this was also its major disadvantage. The bulbs ment of a stereotactic sense.° 5 6 Finally, the emitted heat and required constant cooling. A large arthroscopist must have the instruments and be inventory of bulbs had to be maintained. The familiar with them. possibility of breakage during the procedure was In the early 1970s, there were only a few surgical always present. Due to these factors, most arthro- instruments, which consisted of biopsy forceps and scopes utilized a fiberoptic illumination system by scissors. Currently, there are 3, 4, and 5 mm. the mid-1970s. This gave the advantages of a cooler surgical instruments, including various knives, instrument, a remote light source out of the surgi- scissors, grasping forceps, probes, cutting forceps, cal field, and, most important, less fragility and baskets, instruments with retractable blades, and subsequent breakage. rongeurs.8, li" 15 There are also ribbed Teflon sleeves There are many types of arthroscopes now avail- for use in polypuncture technique to reduce trauma

818/82 August 1981/Journal of AOA/vol. 80/no. 12 to the entry wound and facilitate the change of almost impossible to identify. 15 Removal of loose instruments. There are instrument guides that bodies under arthroscopic control is usually the aid in triangulation and avoid the disorientation first endoscopic procedure undertaken once the usually associated with the introduction of acces- loose body is located. The procedure is usually sim- sory instruments. 9 Finally, there are motorized ple. The difficulty encountered is finding the loose instruments, most notably the intra-articular shav- body and then keeping it within the field of vision. er, which initially was developed for the shaving of Loose bodies can be either free or pedunculated, the patella but also can be used for debridement of which can complicate this process." The loose body areas of the femoral condyle and tibial plateau; also can be hidden in synovial fronds or villi.5 excision of the medial shelf, adhesions, or plicas; There are several techniques for removal of loose removal of loose bodies; and trimming of the bodies, with minor variations. It is agreed that ease margin of the meniscus in partial meniscectomy.") of removal is facilitated if the loose body can be At present, surgical techniques are highly indi- mobilized into the suprapatellar fossa.8, 10, 15 This 10,13 vidualized. Arthroscopic procedures are per- allows considerably more room for instrumenta- formed by using variations of the polypuncture tion. Both the single- and double-puncture tech- technique. The diagnostic arthroscope and two niques utilize the enlarging incision procedure other portals or the operating arthroscope and one after the loose body has been grasped. After grasp- other portal may be used. The Japanese introduced ing, attempts are made to manipulate the loose the two-puncture and three-puncture techniques body so that its smallest diameter is tenting the in meniscus surgery with the diagnostic arthroscope. skin. The incision is slowly enlarged while traction Their follow-up has shown no difference in results. and teasing are performed on the loose body. The Thus, the three-puncture technique is recommended incision does not have to be as large as the loose because traction can be more easily applied and body. Guhl") reported removing a 2.5 cm. loose there is no chance of losing a detached flap.5 body through a 6 mm. incision. A variation of this There are arthroscopic techniques for removal of procedure, after grasping the loose body with the loose bodies, 8, ", 5 excision of medial synovial forceps, is to push it against the skin in the sup- plica,8 10, 15 treatment of osteochondritis dessi- rapatellar fossa. cans,6A 15 and chondromalacia," lateral retinacu- In the single-puncture technique, the loose body lar release," meniscoresis repair of cartilage,5 is localized with the arthroscope, and the arthro- synovectomy,3 and, probably most important, men- scope is removed and replaced with grasping for- iscectomy. 4 5, 8 10, 13, 15 The results of these pro- ceps. The loose body is grasped and the enlarging cedures have been more than gratifying, showing incision procedure is used. OConnor 5 recommends the advantages of arthroscopic surgery over con- this technique for removal of large osteocartilagin- ventional arthrotomy. These advantages include ous bodies in the intercondylar region, suprapatel- the following4. 8, 10, 15 : (1) Rapid rehabilitation lar recess, or medial or lateral gutters. with rapid return to the pre-injury level, especially In the double-puncture technique, the arthro- significant in athletic competition; (2) ability to scope localizes the loose bodies and a second inci- perform most surgery on an outpatient basis, sion is made for the introduction of a grasping in- thereby reducing hospital costs; (3) cosmetic, mul- strument. The loose body is worked into the sup- tiple small incisions as compared with a disfigur- rapatellar pouch, unless it is in the lateral or me- ing scar; (4) very low complication rate, with a very dial gutters. It is removed by the enlarging incision low incidence of thrombophlebitis and infection; procedure. This technique is recommended for very and (5) ability to perform a secondary arthroscopy mobile osteocartilaginous bodies and medium- or procedure with subsequent low morbidity. sized loose bodies.5 Arthroscopic surgery has been gaining increased The irrigation technique is most applicable to the acceptance in the past few years, but that does not removal of cartilaginous loose bodies, especially eliminate the need for arthrotomy. Initially, arthro- those lying in the joint line. It does not work as well scopic procedures are quite time consuming. Time with osteocartilaginous bodies because they tend to limits are recommended, varying from 1 1/2 to 2 be larger and denser, making them less buoyant. hours, if in which the procedure is not completed, After localization of the loose body by arthroscopy, then arthrotomy is performed." A discussion of the either a Toomey or Ellick syringe is introduced various arthroscopic surgical procedures previously through the incision. The Toomey syringe is pre- delineated follows. ferred because it produces greater negative pres- sure. Loose bodies Guhl8 suggests two other techniques for special Loose bodies in the knee are either cartilaginous or cases. If the loose body can be localized prior to osteocartilaginous. Standard radiographic exam- arthroscopy, he suggests stabilizing it with a ination of the knees usually can identify osteocar- hypodermic needle, then bringing it out through a tilaginous loose bodies that are greater than 8 mm. small incision directly over it. For larger loose bod- in diameter, whereas cartilaginous loose bodies are ies, the intra-articular shaver may be of value.

Arthroscopic surgery of the knee 819/83 Synovial shelf or medial synovial plica or medial tachment, or craters and loose bodies. Craters and intra-articular bands and adhesions loose bodies are evaluated further as being salvage- Hypertrophy of the medial synovial plica can cause able or unsalvageable.6. 8 A probe and an injection symptoms that mimic internal derangement of the of methylene blue aid arthroscopic evaluation.6 knee. This synovial band arises from the medial The various treatments consist basically of drill- suprapatellar area and passes between the medial ing only for intact lesions; drilling and perhaps facet of the patella and the medial femoral condyle, inserting one or two pins for early separation; re- finally attaching to the fat pad. 15 It is postulated duction, drilling, and pinning partially detached that a knee which undergoes repeated twisting or lesions and salvageable loose bodies; and drilling contusion-type trauma, particularly in the area of and bone grafting for unsalvageable loose bodies. the medial femoral condyle, suffers hypertrophy of Arthroscopic management of osteochondritis de- the medial synovial plica. As it hypertrophies, it ssicans in Guhls series of twenty-three patients also can become fibrosed. The symptomatology is (five with bilateral involvement) showed that two caused as the hypertrophied plica "bowstrings" experienced healing with conservative treatment over the medial femoral condyle during flexion.° alone and twelve with surgical treatment. Six ex- The arthroscopic surgeon has the choice of divi- perienced satisfactorily progressive healing and so sion or wedge resection of this tough synovial band. did five others but preexisting incongruity due to Short-term results have been pleasing, but as of yet degenerative changes or craters ultimately may there are no long-term results. When the operating alter their prognosis. The complications in this arthroscope is used, the suprapatellar single- series were two patients with pin breakage, two puncture technique is selected. The procedure also with pin erosion, one with questionable pin tract can be performed with the double-puncture tech- infection, and two with chondromalacia patella nique by using the diagnostic arthroscope through probably secondary to immobilization. These ini- a suprapatellar puncture and the second instru- tial results are promising but long-term evaluation ment, either scissors or intra-articular shaver, will take decades.6 through the anterolateral approach. Guh1,6 8 in his series of seventeen knees, produced Chondroplasty complete relief in thirty-one knees and satisfactory In the treatment of chondromalacia patella, arthrot- relief in sixteen knees. Improvement was noticed omy has produced unrewarding long-term results.° from a few days to a few weeks postoperatively. Use of an intra-articular shaver under arthroscop- OConnor,i5 in a series of eighteen patients, reported ic control has shown good early postoperative definite improvement in fourteen. Of the remaining results, but the value of this procedure is yet to be four, one was lost to follow-up, one also had two determined. The patella is shaved, using a three- loose bodies removed at the time of surgery, and puncture technique for the diagnostic arthroscope two definitely had no improvement. These two anterolaterally, the intra-articular shaver, and ir- were later found to have subluxing patellae. rigation through suprapatellar portals. Adhesions can occur postoperatively or posttrau- matically. They usually produce symptoms of pain Lateral retinacular release and limitation of motion. Current treatment con- The lateral retinacular release can be used in the sists of manipulation, distention, and lyses with a treatment of the lateral tracking syndrome. The dull obturator. If the aforementioned treatments, indications for lateral retinacular release include especially manipulation, fail or are contraindicated, patellofemoral symptoms of pain or instability, adhesions can be cut in a similar manner as the failure of a conservative exercise program, and evi- plica. Guhl t° reported that seven of eight patients dence of one objective criterion. If the patient showed dramatic relief. meets all of these criteria, then diagnostic arthros- copy is performed to document at least a 20 per- Osteochondritis dessicans cent lateral patellar overhang when the knee is Conservative treatment of osteochondritis dessi- flexed 45 to 60 degrees. If this is absent, there is no cans has not had the most satisfactory results. indication for surgery. Early results of arthroscopic management have in- The first part of the procedure is the blind use of dicated that arthrotomy should be avoided if Mayo scissors through the anterolateral approach possible. The objectives of treatment are threefold: to cut the synovium, capsule, and fibers of the vas- (1) save or improve the articular surface, (2) obtain tus lateralis. The remainder of the cutting is done healing, and (3) prevent arthritis. 6 After a thor- under arthroscopic control. Release is sufficient ough arthroscopic evaluation, surgical candidates when the lateral overhang disappears and there is are those with lesions much greater than 1 cm. in normal articulation at 40 to 60 degrees of flexion. size and with a skeletal age over 12. The intra-articular shaver then is used for any The surgical procedure chosen depends on the areas of chondromalacia. arthroscopic evaluation which classifies the lesion In McGintys series of thirty-two patients fol- as showing intactness, early separation, partial de- lowed up for 32 months, eighteen had no symptoms,

820/84 August 1981/Journal of AOA/vol. 80/no. 12 twelve improved but had residual symptoms that as the lesion. If the diagnostic arthroscope is used, were not sufficient to interfere with activities, and it is placed through the opposite side. Additional two remained unchanged. In addition to previously portals then are made for the accessory instru- mentioned advantages of arthroscopic surgery, this ments. The intra-articular shaver may or may not procedure does not preclude more involved recon- be used. structive procedures in the future. Postoperatively the knee is dressed with only a 6-inch Ace bandage4 or a soft pressure dressing of Meniscoresis cotton and Ace bandages from ankle to groin." The Meniscoresis has been performed in patients who patient is completely ambulatory without support have parameniscal tears usually involving the an- after he recovers from anesthesia and he is usually terior or middle portions of the meniscus. The proce- discharged 2 hours after surgery. Before discharge, dure is done to prevent any further loosening or dis- he is instructed in straight-leg raising and quad- location of the meniscus. Diagnostic arthroscopy is riceps setting exercises; also, a smooth gait pattern performed while the knee is placed through repeated is established. Within a week, heavy progressive flexion and extension. This should identify the resistance quadriceps exercises in the final arc of areas of parameniscal tears to be repaired. Menis- extension are started. Ascriptin is used for its anti- coresis then is performed by placing sutures through inflammatory and anticoagulant effects. 4 OCon- the skin meniscus to the outer edge of the outside of nor" recommends a 24-hour postoperative check. If the skin under arthroscopic control. The knee then effusion is present, arthrocentesis is performed and is immobilized with a plaster cast for 3 weeks to the patient is kept on non-weight-bearing support allow good fixation by scar tissue. until the effusion comes under control. Guhl8 Of the six patients in Ikeuchis series, four had recommends suture removal be held until the tenth excellent results and two later underwent total to fourteenth day postoperatively to prevent sinus meniscectomy with subsequent relief.5 tract formation from the trauma of surgery. Fi- nally, Carson4 conducts postoperative muscle eval- Meniscectomy uation on the Orthitron. The ability to perform a meniscectomy or partial The overall results of surgery have been more meniscectomy is probably the greatest break- than satisfactory. Guhl 8 reported that the clinical through in arthroscopic surgery. The techniques symptoms and response to anterior horn tear were for this procedure vary the most, although it is dramatic. Ikeuchi 5 performed partial meniscec- believed that almost all meniscal lesions can be tomy in thirty-five patients, of whom thirty-three treated endoscopically. es 1° Whether they should be had satisfactory results while the remaining two arthroscopically removed depends on the length of had to undergo total meniscectomy due to instabil- time required for removal. A complete diagnostic ity of the remaining meniscus. Carson 4 performed arthroscopic evaluation using a probe should be sixty-five meniscectomies in fifty-nine patients performed to determine the extent of the tear. Also, and a 13-month follow-up. Patients had complained the knee joint should be manipulated while the of swelling and sensations of pain, limpness, catch- meniscus is observed. If the tear stretches to the ing, locking, and giving way of the knee. Even with parameniscal area, partial meniscectomy is not in- these complaints, no patient thought the severity dicated.5 On the basis of these facts, OConnor has was sufficient to undergo an arthrogram or a sec- developed a classification of meniscal tears amen- ond diagnostic or operative procedure. Carsons able to arthroscopic partial meniscectomy8. 15: (1) patients returned to work as soon as the day after oblique tear, posterior horn medial meniscus; (2) surgery to approximately 2 weeks after surgery for flap tear, lateral meniscus; (3) transverse tear, heavy laborers. OConnor has yet to publish his re- lateral meniscus; (4) longitudinal tear, posterior sults. horn lateral meniscus; (5) bucket handle tear, Overall, complications have been minimal. The medial meniscus; and (6) bucket handle tear, most common complication appears to be hemar- lateral meniscus. throsis4. 15 or effusion, 5,5 which can be managed by In performing the partial meniscectomy, the sta- aspiration and usually resolves in one month. bility of the retained part has to be verified by Guhl5 and Carson4 both reported a low incidence of manipulation." As opposed to the partial menis- thrombophlebitis; one patient in Carsons study cectomy, Carson4 suggests subtotal excision of the had multiple, small pulmonary emboli. Both Car- posterior two thirds of the meniscus, particularly son4 and Ikeuchi5 had no cases of infection. Guhl5 on the medial side. The posterior compartments are reported two patients with wound infections sec- least accessible for arthroscopic evaluation by the ondary to premature removal of sutures. anterolateral or anteromedial approach. Arthros- copic meniscectomy or partial meniscectomy uses Synovectomy the polypuncture technique with the diagnostic or Synovectomy has been performed with a modified operative arthroscope. If the operative arthroscope electric resectoscope by the Japanese. The resecto- is used, it is inserted anteriorly on the same side scope is a cystoscope that has been improved and

Arthroscopic surgery of the knee 821/85 modified for use in the knee joint. It has a semi- been done through endoscopes to control expe- circular tungsten loop through which a high-inten- rimental erosive bleeding of the gastrointestinal sity current flows. Thus, the instrument can be used tract. 17 The laser is being used in for the to resect tissue and achieve hemostasis. treatment of bladder tumors and urethral stric- In the rheumatoid patient, pain and effusion tures. With the laser, there is no problem with from chronic disease as well as a clinical assess- residual debris because the tissue is vaporized.18 ment that shows a high degree of inflammatory Laser meniscectomy is a reality, but it just requires activity are indications for synovectomy. Conven- expertise to direct it and make it safe. tional synovectomy has been shown to result in loss of motion, prolonged recovery, and a high incidence Summary of recurrence. Synovectomy with an elastic resecto- In this review of the arthroscopic surgical proce- scope used in a similar manner when a transure- dures currently available, it has been shown that thral resection is performed has resulted in a rapid they offer considerable advantages over arthrotomy. recovery time, usually without postoperative manip- Despite the minor disadvantages already encoun- ulation, and a considerably shortened hospital tered, arthroscopic surgery may be the preferred stay. As of yet, this has not gained any widespread procedure in the future. The knee is just the first acceptance in the United States. joint amenable to arthroscopic surgery. However, the skill and confidence gained through the proce- Discussion dures used in arthroscopic knee surgery will be After this brief review of the arthroscopic proce- applicable to other joints of the body. dures currently available, one is definitely im- pressed with the lower morbidity, the shorter reha- 1. Wetterman, L.A.: From Endoscopy to arthroscopy. In Arthroscopy, edited by R.L. OConnor. J.B. Lippincott Co., Philadelphia, 1977, pp. 1-11 bilitation period, and the reduced costs. Although 2. Joyce, J.J., III: History of arthroscopy. In Arthroscopy, edited by R.L. arthroscopic surgery represents a realistic choice OConnor. J.B. Lippincott Co., Philadelphia, 1977, pp. 12-16 over arthrotomy, it does have some disadvantages. 3. Aritomi, H., and Yamamoto, M.: A method of arthroscopic surgery. Clinical evaluation of synovectomy with the electric resectoscope and First, considerable experience is necessary. It is removal of loose bodies in the knee joint. Orthop Clin North Am 10: recommended that 300 to 500 diagnostic arthroscop- 565-84, Jul 79 4. Carson, R.W.: Arthroscopic meniscectomy. Orthop Clin North Am ies be performed prior to undertaking a surgical 10:619-27, Jul 79 procedure.° There are not many training programs 5. Ikeuchi, H.: Meniscus surgery using the Watanabe arthroscope. Or- that provide that volume and as of yet there are no thop Clin North Am 10:629-42, Jul 79 6. Guhl, J.F.: Arthroscopic treatment of osteochondritis dissecans. Pre- fellowships in arthroscopic surgery. Second, a large liminary report. Orthop Clin North Am 10:671-83, Jul 81 investment in instruments and equipment is neces- 7. Janecki, C.J., Jr., Hill, D.H., and Eubanks, R.G.: Arthroscopy of the sary. Two diagnostic arthroscopes, operating arthro- knee. Am Fam Physician 17:109-16, Mar 78 8. Guhl, J.F.: Operative arthroscopy. Am J Sports Med 7:328-35, Nov- scope, accessory instruments, intra-articular shav- Dec 79 er, light source, and the necessary equipment for 9. Carson, R.W.: Arthroscopic instrument guide. Orthop Rev 7:127-8, videorecording and documentation can run $35,000. Sep 78 10.McGinty, J.B.: Arthroscopy of the knee. Update and review. Orthop Third, it is a difficult and tedious microsurgical Dig 7:17-35, Nov-Dec 79 procedure. In the initial cases, many technical 11.McGinty, J.B., and Matza, R.A.: Arthroscopy of the knee. Evalua- difficulties are encountered and the operative time tion of an out-patient procedure under local anesthesia. J Bone Joint Surg 60-A: 787-9, Sep 78 is prolonged. Both of these do improve with experi- 12.Pevey, J.K.: Outpatient arthroscopy of the knee under local anes- ence. Fourth, the procedure is carried out under thesia. Am J Sports Med 6:122-6, May-Jun 78 questionable sterility. Fortunately, this has not 13.Watanabe, M.: Arthroscopy: The present state. Orthop Clin North Am 10:505-22, Jul 79 been borne out by studies and the infection rate has 14.Korn, M.W., Spitzer, R.M., and Robinson, K.E.: Correlations of ar- been almost nil. Fifth, as with any mechanical or thrography with arthroscopy. Orthop Clin North Am 10:535-43, Jul 79 electrical device, instrument breakage is a poten- 15.OConnor, R.L., ed. Arthroscopy. J.B. Lippincott Co., Philadelphia, 1977, pp. 76-9, 116-46 tial hazard. Finally, there has been insufficient 16. Whipple, T.L., and Bassett, F. H., III: Arthroscopic examination of the time to evaluate or appreciate the intra-articular knee. Polypuncture technique with percutaneous intra-articular manip- complications of inadvertent damage to the articu- ulation. J Bone Joint Surg 60:444-53, Jun 78 17.Silverstein, F.E., et al.: High power argon laser treatment via stan- lar surface by instruments and the effects of dard endoscopes. I. A preliminary study of efficacy in control of expe- residual debris following a procedure. Scuffing of rimental erosive bleeding. Gastroenterology 71:558-63, Oct 76 the articular surfaces is a definite danger. With 18.Billow, I.T.: Present status of endoscopic laser techniques in urology. Endoscopy 4:240-3, 79 careful technique and advances in instrumenta- tion, this should be minimized. In follow-up arthros- Accepted for publication in May 1981. Updating, as necessary, copy OConnor5 has shown that areas of scuffing has been done by the author. tend to heal without further extension. This paper was awarded third place in the 1980 Ethicon Writ- ing Competition through the American Osteopathic Academy of Arthroscopic surgery is in its infancy. Surgical Orthopedics. techniques have room for improvement and re- finement as well as does instrumentation. Applica- Dr. Fraider is a fourth-year resident in at tion of laser technology is not far off in the future. the Philadelphia College of Osteopathic Medicine, Phila- delphia, Pennsylvania, of which Dr. J. Brendan Wynne is divi- Laser photocoagulation already is feasible and has sional chairman. Address, 4150 City Ave., Philadelphia, 19131.

822/86 August 1981/Journal of AOA/vol. 80/no. 12